Cervical Radiculopathy Presenting as Ischemic Stroke After Carotid Artery Stent Placement.

Abrupt loss of focal brain function is the main characteristic of the beginning of ischemic stroke. However, individuals with disorders other than stroke can also present with similar features. These conditions include seizure disorders, migraine, central nervous system abscess or tumor, head trauma, subdural hematoma, cerebral venous thrombosis, viral encephalitis, conversion reaction, hypertensive encephalopathy, multiple sclerosis, and spinal cord disorder. An 82-year-old man presented with a sudden onset of numbness in his left forearm in the distribution of C6 and C7 spinal nerves, 2 days after undergoing endarterectomy and stent placement in his right carotid artery because of stenosis. He was diagnosed with hypo-pharyngeal squamous cell carcinoma (T1, L0, M0) 17 years earlier (2006) which was treated with 70 Gy intensity-modulated radiotherapy (IMRT). The patient underwent stent insertion into his left carotid artery 3.5 years earlier because of 80% carotid artery stenosis. He was initially suspected to have an ischemic stroke. However, computed tomography angiography of the head and neck did not show stenosis or occlusion of the major intracranial arteries and no aneurysms were identified. It showed interval stenting of the cervical portion of the right carotid artery and stable appearance of left carotid artery stent. Both carotid artery stents and the vertebral arteries were patent. The cervical spine showed bilateral moderate to severe foramen stenosis in C3-C4 and C5-C6, and moderate to severe stenosis in the right C2-C3 and left C4-C5. His symptoms subsided after performing neck extension exercises. This is the first report of a patient whose cervical radiculopathy symptoms were suspected to be caused by ischemic stroke. The recent angioplasty and stent placement in the right carotid artery made the association more likely and had to be excluded. Clinicians should be aware that cervical radiculopathy could present as ischemic stroke. It is therefore important that disorders that cause symptoms similar to ischemic stroke are also considered in these individuals.

Correction of carotid artery stenosis by stent placement ameliorated paroxysmal hypertension after radiation treatment of hypopharyngeal carcinoma: a case report.

BACKGROUND: Paroxysmal hypertension can be associated with failure of the carotid artery baroreceptors due to past exposure to radiation treatment. This report describes a patient whose repeated paroxysmal hypertensive episodes were ameliorated following placement of a carotid artery stent for the treatment of carotid artery stenosis. CASE REPORT: A 79-year-old caucasian male was diagnosed with hypopharyngeal squamous cell carcinoma (T1, L0, M0) in 2006, and received 70 Gy intensity-modulated radiotherapy in 2006 and underwent a total laryngectomy in 2008. He experienced paroxysmal hypertensive episodes since 2010 that exacerbated in frequency in 2019. Eighty percent left internal carotid artery stenosis was demonstrated by ultrasound and arteriography. Angioplasty and stenting of the left carotid artery was performed. A Doppler ultrasound study performed 5 months after the stent placement did not reveal any hemodynamic stenosis in the left carotid artery. The patient experienced postprandial hypotension and had experienced only three episodes of paroxysmal hypertension in the following 24 months. He was able to abort paroxysmal hypertensive episodes by eating warm food. DISCUSSION: This is the first report of a patient whose paroxysmal hypertensive episodes that occurred following radiation of the neck subsided after placement of a stent in a stenotic carotid artery. The exact mechanism leading to this phenomena is unknown but may be due to several factors. The reversal of the carotid artery stent and improvement in blood flow to the carotid artery baroceptors may play a role in this phenomenon. CONCLUSION: The ability to ameliorate paroxysmal hypertensive episodes in a patient with carotid artery stenosis by stent placement may be a promising therapeutic intervention for paroxysmal hypertension.

A Case of Neurosarcoid Presenting as Multiple Intraparenchymal Hemorrhages.

This report explores the case of a 49-year-old African American male with a six-month history of multifocal neurological deficits who presented to an outside hospital after a generalized seizure. Patient was transferred to our tertiary medical center after brain imaging showed multiple bilateral supratentorial intraparenchymal hemorrhages (IPH). A brain biopsy confirmed parenchymal and perivascular non-caseating granulomas with vasculitis. The patient was definitively diagnosed with neurosarcoidosis (NS) and his condition improved with high dose corticosteroids and additional immunosuppressive therapies. Intracranial hemorrhage in the setting of NS is extremely rare, with fewer than thirty documented cases; however, this is likely an underestimation of its true prevalence. This case illustrates the difficulty in diagnosis as many other etiologies of IPH must be considered. Additionally, the clinical course and manifestations of NS is often quite variable. The uniqueness of this case lies in the rapid progression from seemingly incidental microhemorrhages to multiple large IPHs over two months. While the cause of this progression is not immediately apparent, a possible cause may be inadequate initial treatment due to delayed diagnosis. Our case demonstrates the importance of early recognition and initiation of immunosuppressive therapy, potentially leading to dramatic clinical improvement, as seen in this patient.

Arteriovenous Malformations Treated With Frameless Robotic Radiosurgery Using Non-Invasive Angiography: Long-Term Outcomes of a Single Center Pilot Study.

OBJECTIVE: CT-guided, frameless robotic radiosurgery is a novel radiotherapy technique for the treatment of intracranial arteriovenous malformations (AVMs) that serves as an alternative to traditional catheter-angiography targeted, frame-based methods. METHODS: Patients diagnosed with AVMs who completed single fraction frameless robotic radiosurgery at Medstar Georgetown University Hospital between July 20, 2006 - March 11, 2013 were included in the present study. All patients received pre-treatment planning with CT angiogram (CTA) and MRI, and were treated using the CyberKnife radiosurgery platform. Patients were followed for at least four years or until radiographic obliteration of the AVM was observed. RESULTS: Twenty patients were included in the present study. The majority of patients were diagnosed with Spetzler Martin Grade II (35%) or III (35%) AVMs. The AVM median nidus diameter and nidal volume was 1.8 cm and 4.38 cc, respectively. Median stereotactic radiosurgery dose was 1,800 cGy. After a median follow-up of 42 months, the majority of patients (81.3%) had complete obliteration of their AVM. All patients who were treated to a total dose of 1800 cGy demonstrated complete obliteration. One patient treated at a dose of 2,200 cGy developed temporary treatment-related toxicity, and one patient developed post-treatment hemorrhage. CONCLUSIONS: Frameless robotic radiosurgery with non-invasive CTA and MRI radiography appears to be a safe and effective radiation modality and serves as a novel alternative to traditional invasive catheter-angiography, frame-based methods for the treatment of intracranial AVMs. Adequate obliteration can be achieved utilizing 1,800 cGy in a single fraction, and minimizes treatment-related side effects.

Venous sinus compromise after pre-sigmoid, transpetrosal approach for skull base tumors: A study on the asymptomatic incidence and report of a rare dural arteriovenous fistula as symptomatic manifestation.

The sigmoid sinus is routinely exposed and manipulated during pre-sigmoid, transpetrosal approaches to the skull base, but there is scant data available on the incidence of venous sinus compromise after surgery. We encountered a dural arteriovenous fistula as a result of sigmoid sinus occlusion and examined the incidence of venous sinus thrombosis or narrowing after transpetrosal surgeries. We performed a retrospective analysis of a series of patients treated by the senior surgeons (WCJ, MH, HJK), who underwent either a posterior petrosectomy or translabyrinthine approach for various skull base tumors. All available clinical and radiographic data were thoroughly examined in each patient to determine the post-operative fate of the venous sinuses. Of the 52 available patients, five patients were discovered post-operatively to have a narrowed or constricted sigmoid sinus ipsilateral to the surgery, whereas another five patients were diagnosed with asymptomatic sinus thrombosis either in the transverse or sigmoid or both. None of these patients experienced symptoms, nor were there any instance of ischemic or hemorrhagic complications. However, there was one additional patient who presented with pulsatile tinnitus 2years after surgery. His angiogram showed an occlusion of the ipsilateral sigmoid sinus and a posterior fossa dural arteriovenous fistula. A two-stage transvenous and transarterial embolization was successful in eliminating the fistula. Technical considerations to avoid sinus injuries during pre-sigmoid, transpetrosal surgery are discussed.

Intermittent balloon occlusion to favor nidal penetration during embolization of arteriovenous malformations: a technique modification.

Endovascular embolization of brain arteriovenous malformations (AVMs) has improved with liquid occlusive agents, but flow-related and anatomic restrictions limit endovascular capabilities. AVM compartments supplied by leptomeningeal networks and feeding arteries too small and/or tortuous for safe catheterization are rarely penetrated by liquid occlusive agents. A case with both impediments prompted a novel solution. A balloon was inflated across the supply to a lenticulostriate feeder, thereby favoring penetration of the liquid occlusive agent, injected from a different feeding territory, back into the AVM compartment supplied by the temporarily occluded feeder. This technique may reduce the number of embolization stages in large high-flow AVMs and increase the likelihood of achieving complete occlusion. This technique is highly complex and requires meticulous monitoring of multiple events.

Acute embolization of ruptured brain arteriovenous malformations.

BACKGROUND: Ruptured brain arteriovenous malformations (bAVMs) are at increased risk of re-hemorrhage but management has historically been conservative. This is because: (1) ruptured bAVMs have not been considered as catastrophic as ruptured cerebral aneurysms, (2) surgical resection is aided by waiting for brain edema to resolve and clot to liquefy and (3) fear exists that partially treated bAVMs may be more dangerous than those untreated. The purpose of this study was to determine the feasibility and safety of acute embolization in patients with ruptured bAVMs. METHODS: 21 consecutive patients who underwent acute embolization of ruptured bAVMs from 2007 to 2011 were retrospectively reviewed. All treatments consisted of embolization exclusively using Onyx liquid embolic agent. Neurological outcomes were assessed using the Glasgow Outcome Scale (GOS) at hospital discharge following initial treatment. RESULTS: Nine patients (43%) were male, mean age was 38 years (range 8-75) and initial embolization was performed at a median of 4 days after ictus (mean 5.8, range 0-19). Spetzler-Martin grades ranged from I to VI (mean 3, median 3). In seven patients (33%) the AVM was completely occluded with a single treatment. With subsequent embolizations, complete occlusion occurred in four additional patients (19%). Six patients (29%) had post-embolization AVM resection and one patient (5%) had post-embolization gamma knife irradiation. None has suffered subsequent hemorrhages (mean follow-up 7.5 months). The mean discharge GOS of all patients was 4.4 (range 1-5). CONCLUSION: Treatment of ruptured bAVMs is often delayed but our experience with Onyx suggests that acute embolization is safe and feasible.

Transcranial laser therapy for acute ischemic stroke: a pooled analysis of NEST-1 and NEST-2.

BACKGROUND: NeuroThera Effectiveness and Safety Trials (NEST) 1 and 2 have demonstrated safety of transcranial laser therapy (TLT) for human treatment in acute ischemic stroke. NEST 1 study suggested efficacy of TLT but the following NEST 2, despite strong signals, missed reaching significance on its primary efficacy endpoint. In order to assess efficacy in a larger cohort, a pooled analysis was therefore performed. METHODS: The two studies were first compared for heterogeneity, and then a pooled analysis was performed to assess overall safety and efficacy, and examined particular subgroups. The primary endpoint for the pooled analysis was dichotomized modified Rankin scale (mRS) 0-2 at 90 days. RESULTS: Efficacy analysis for the intention-to-treat population was based on a total of 778 patients. Baseline characteristics and prognostic factors were balanced between the two groups. The TLT group (n = 410) success rate measured by the dichotomized 90-day mRS was significantly higher compared with the sham group (n = 368) (P = 0·003, OR: 1·67, 95% CI: 1·19-2·35). The distribution of scores on the 90-day mRS was significantly different in TLT compared with sham (P = 0·0005 Cochran-Mantel-Haenszel). Subgroup analysis identified moderate strokes as a predictor of better treatment response. CONCLUSIONS: This pooled analysis support the likelihood that transcranial laser therapy is effective for the treatment of acute ischemic stroke when initiated within 24 h of stroke onset. If ultimately confirmed, transcranial laser therapy will change management and improve outcomes of far more patients with acute ischemic stroke.

The evolution of transcranial laser therapy for acute ischemic stroke, including a pooled analysis of NEST-1 and NEST-2.

Intravenous tissue plasminogen activator is the only proven therapy for acute ischemic stroke. Not enough patients are eligible for treatment and additional new therapies are needed. Recently, laser technology has been applied to acute ischemic stroke. This noninvasive technique uses near-infrared wavelengths applied to the scalp within 24 h of symptom onset. The mechanism is incompletely understood but may involve increased mitochondrial adenosine triphosphate production. Animal models demonstrated safety and efficacy warranting randomized controlled trials in humans. NEST-1 (phase 2) and NEST-2 (phase 3) confirmed the safety of transcranial laser therapy, although efficacy was not found in NEST-2. Pooled analysis of NEST-1 and NEST-2 revealed a significantly improved success rate in patients treated with laser therapy. Further phase 3 testing is planned and may create a new paradigm for the treatment of acute ischemic stroke.